A.D. HENDERSON UNIVERSITY SCHOOL FAU HIGH SCHOOL ENROLLMENT PACKET

2013-2014 A.D. HENDERSON UNIVERSITY SCHOOL FAU HIGH SCHOOL ENROLLMENT PACKET FORMS TO BE COMPLETED BY PARENTS OF NEWLY SELECTED STUDENTS Student Name Entering Grade Page 1 of 9

A.D. HENDERSON UNIVERSITY SCHOOL FAU HIGH SCHOOL 2013-2014 Dear Parents or Guardians: It is our pleasure to offer admission to your son or daughter to Alexander D. Henderson University School / FAU High School for the 2013-2014 school year. Please print and complete the following forms and return them to the FAU Schools office, 777 Glades Road, Boca Raton, FL 33431. ADMISSION IS CONTINGENT ON PROVIDING THE FOLLOWING: Documents/Forms Parents/Guardians have to submit Students Entering Kindergarten 1 Birth Certificate An Original (we will copy and return to you) 2 Social Security Card An Original (we will copy and return to you) 2 Students Entering 1 st Through 12 th Gr. A Copy A Copy IMPORTANT NOTES If lost, please apply for a new one. If lost, please apply for a new one at SSA office and provide the confirmation. When received, please provide the actual SSC. 3 Immunization Record (DH-680) An Original An Original Form should include the dates of immunization. Students will not be allowed to start school without DH-680 Form 4 Physical Exam (DH-3040) An Original An Original Exam must be performed after August 20, 2012. Form must be completed on both sides, page one completed by the parent, page two completed by the doctor. Students will not be allowed to start school without DH-3040 Form 5 IEP(Individual Educational Plan) If applicable 6 Final Report Card 2012-13 (after the end of the school year) 7 EOC Assessment student results (Algebra 1, Geometry, Biology 1, U.S. History, Civics Education) 8 FCAT or Standardized Test Scores 2012-13 (after the end of the school year) A Copy A Copy FAILURE TO DISCLOSE SPECIAL NEEDS COULD RESULT IN REVOKING THE INVITATION TO ATTEND. N/A A Copy For students entering grades 2 8, the prior 2 years Report Cards (For example, if your child is entering 5 th Gr. you must send 4 th, 3 rd Gr. Report Cards.) For the students entering grades 9-12, an official transcript. N/A A Copy For students entering grades 8 12, End-of-Course Assessment (EOC) results. N/A A Copy For students entering grades 2 8, the prior 2 years Test Scores. (For example, if your child is entering 5 th Gr. you must send 4 th, 3 rd Gr. Test Scores.) For the students entering grades 9-12, an official transcript. 9 Student Information Form (pg. 3,4) An Original An Original Please print and do not leave any area unanswered. If not applicable, use - NA 10 Health Forms (pg. 5-8) An Original An Original Please print and do not leave any area unanswered. If not applicable, use - NA 11 Alert Now Information Form (pg.9) An Original An Original Please print and do not leave any area unanswered. If not applicable, use - NA Note: Florida Law requires that the immunization and physical be up-to-date and on file before a child enters school. Please keep in mind that final admission to the school is based on our receipt of a complete and accurate Enrollment Packet. For students entering KG through 8 th Gr., we must receive your Enrollment Packet no later than 5 days of the acceptance date. If we have not received the required documents at that time we will assume that you are not interested in admission and will select the next applicant. Thank you for your cooperation. We look forward to having you and your son or daughter join our school.

Florida Atlantic University Schools Student Information Form 2013-2014 1. Complete ALL AREAS of the form. STUDENT LEGAL NAME - LAST NAME FIRST NAME MIDDLE NAME ALSO KNOWN AS LOCAL ADDRESS (house # and street name) APT. # CITY STATE ZIP CODE MAILING ADDRESS IF DIFFERENT (house number, street name, apartment number, city, state, zip code) HOME TELEPHONE NUMBER - - SEX (M/F) RESIDENT STATUS DATE OF BIRTH (mm/dd/yyyy) / / STUDENT SOCIAL SECURITY NUMBER - - ENTERING GRADE PLACE OF BIRTH (city, state, country) RACE/ETHNIC ORIGIN a) Is your child Hispanic or Latino? (Please, mark only one) YES NO b) What is your child s race? I American Indian/Alaskan Native P Native Hawaiian or A Asian Other Pacific Islander B - Black or African American W - White US CITIZEN USA ENTRY DATE NO YES (mm/dd/yyyy) NON-RESIDENT ALIEN PERMANENT RESIDENT ALIEN Foreign Exchange Student Out-of-Country Resident Out-of State Resident In-County Resident Out of County Resident Preschool Enrollment Information (Check each program attended. Indicate with an asterisk [*] the program your child was in the longest.) Fee for Services Head Start Pre-K Disabilities Private Pre-K VPK Program Title I Pre-K Teenage Parent Program None Migrant Pre-K 2. Provide the following parent/legal guardian information. MOTHER/GUARDIAN LAST NAME FIRST NAME FATHER /GUARDIAN LAST NAME FIRST NAME OCCUPATION PLACE OF EMPLOYMENT OCCUPATION PLACE OF EMPLOYMENT ADDRESS IF NOT THE SAME AS STUDENT (house # and street name, city, state, zip) ADDRESS IF NOT THE SAME AS STUDENT (house # and street name, city, state, zip) HOME PHONE WORK PHONE HOME PHONE WORK PHONE CELL PHONE EMAIL ADDRESS (Please print) CELL PHONE EMAIL ADDRESS (Please print) 3. Provide the name(s) of person(s), other than the parent, allowed to pick up student. NAME (last, first, middle initial) RELATIONSHIP TO STUDENT TELEPHONE CELL NUMBER 4. Provide a PASSWORD the person allowed to pick up the student will use. (Limit 10 Characters) 5. TRANSPORTATION: The student listed on this form has permission to use the following method(s) of transportation: CAR WALK PUBLIC BUS BICYCLE TRAIN OTHER 6. Have you filled out an application for free and reduced lunch? YES NO will fill out later 7. This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C. 11435. (Children or youth who lack a fixed, regular, and adequate nighttime residence, including: sharing the housing of others due to loss of housing, economic hardship, or similar reason ( doubling up ); living in motels, hotels, trailer parks, camping grounds due to the lack of adequate alternative accommodations; living in emergency or transitional shelters; abandoned in hospitals) The answers to this residency information help determine the services the student may be eligible to receive. Is your current address temporary living? YES NO Is this temporary living arrangement due to loss of economic hardship? YES NO 3

8. Federal Impact Survey Yes No A. The student resides on federal property. Yes No B. The student resides in low rent housing. Yes No C. The parent is employed on federal property located in Palm Beach County. Yes No D. The parent is employed on low rent housing located in Palm Beach County. Yes No E. The parent is in the uniformed services of the United States. If "E" is YES, is the parent on active duty? (Check service below) Air Force Army Coast Guard National Guard Navy Marines TRANSFER INFORMATION 9. Name of the last school attended A. City State Public School or Private School B. County Country C. Last grade level completed Last attendance date D. Does your child have Individual Education Plan (IEP) 504 Plan Other Plan? (If checked, provide a copy) Not applicable HEALTH SCREENING INFORMATION 10. Students will receive non-invasive health screenings pursuant to Florida Statue 381.0056(7)(d). Non-invasive screenings may include vision, hearing, scoliosis, height, and weight. These tests may be given individually or in groups. Parents or guardians, however, have the right to request an exemption in writing. (This exemption will cover all types of screenings.) If you DO NOT want your child to receive the screenings, write the words "Do not screen" here: 11. Does your child currently have health insurance? Yes No If YES, check insurance plan: Medicaid Healthy Kids/Kid Care Private HOME LANGUAGE SURVEY for NEW STUDENTS TO ADHUS AND FAU HIGH SCHOOL 12. All new students to ADHUS and FAU High School are required to answer the following home language survey questions. Yes No A. Is a language other than English used in the home by parents? If YES, what language? Yes No B. Does the student have a first language other than English? If YES, what language? Yes No C. Does the student most frequently speak a language other than English? If YES, what language? 13. Date Student Entered United States School (first time elementary, middle, or high) /MM/DD/YEAR/ 14. Student lives with: (check one) Both Parents Mother Father Foster Group Home Student is a ward of the state Other Custody Status of Student (check one): Mother Father Shared Custody Person Responsible for payment: Name Address Please circle days of the week for shared custody: DAYS WITH MOTHER - MON TUES WED THURS FRI SAT SUN DAYS WITH FATHER - MON TUES WED THURS FRI SAT SUN Is There A Court Order Barring Either Parent From Removing Or Contacting The Student During The School Day? Yes No If Yes, Provide The School With A Copy Of The Court Order. Verification of Student Registration Information I verify that the information given on this student registration is true and accurate to the best of my knowledge. Signature of Parent/Guardian Date Registration is not valid without a verification signature and date. Signature of Parent/Guardian Date All parents MUST COMPLETE an information form ANNUALLY 4

Clinic Policy and Procedures 2013-2014 A. D. Henderson University School FAU High School College of Education 777 Glades Road Boca Raton, FL 33431 tel: 561.297.3970 fax: 561.297.3939 www.adhus.fau.edu and www.fauhigh.fau.edu The ADHUS/FAU HS Policy and Procedures the nurse must follow in the clinic are listed below. In the event of the following, students are ALWAYS sent home or should NOT come to school: Diarrhea: This is very contagious! Vomiting: To Be Determined by Nurse (gagging on something or sick). Fever: 100 degrees or more (Please DO NOT give your child medication before school that will wear off by the afternoon. Student must have a normal temperature for a period of 24 hours before returning to school. Lice/Nits: We have a NO LICE/NITS POLICY! If your child is suspected of having lice/nits, you must take them to your physician and have them checked. Your child MAY NOT return to school without a note from your physician stating that they do not have either lice/nits. Lice are very contagious just like an illness; we need to keep our students healthy. Please DO NOT send you child to school if you suspect they have lice or nits. Pink Eye: If the teacher and the nurse suspect pink eye, you must have a note from your child s pediatrician Stating they are not contagious before they return to school (as long as it s not chronic allergies TBD by the Nurse). Sore/Red Throat: To be determined by the Nurse, unless the child has known chronic allergies and no fever they may not remain in school. Constant cough/wheezing: Including chest pain. This can be something serious (TBD by nurse). Head/Face Injury: If serious, after 911 is called the parent will be called. Nosebleed (or any other bleeding): Bleeding that does not stop within a reasonable amount of time (15-20 minutes). Skin Eruptions: Contagious or questionable (TBD by nurse). Constant Sneezing (with anything but clear secretion): If the child has only clear secretions and no fever they may remain in school, as long as they use a tissue and wash their hands frequently. Here at Henderson School we strive to keep all our students healthy and safe. Please keep your child/children home if they are sick. When a child becomes sick at school, the nurse will call any and all phone numbers listed on the Emergency Notification form you have completed. Please make sure this form is current. You will have 1 hour to one hour to pick up your child (unless other arrangements have been made with the nurse or the front office personnel due to an unforeseen circumstance). If you do not return the nurse s call or pick your child up within the stated time, the nurse has the right to call the proper authorities which may include 911. We greatly appreciate your full cooperation. Please sign and return by August 1, 2013. If you have any questions, please call Nurse Deborah at (561) 297-2076. Student Name Parent Signature Thank you, Deborah Baltzer An Equal Opportunity/Equal Access Institution

A.D. HENDERSON UNIVERSITY SCHOOL FAU HIGH SCHOOL Health Information and Emergency Notification /Permission for Treatment Form School Year: 2013 to 2014 Date Submitted: Date Revised: Instructions: A separate form is completed for each child in the family who attends ADHUS/FAUHS. A current health information and emergency notification form must be on file in the Health Center when school begins or upon enrollment. Information is updated annually. Additional information changes may be added at any time. It is critical to maintain current contact information at all times. Any information shared is confidential and will be kept in your child s private health care file in the Health Center. It does not become part of the permanent school record. Student s Name: M or F Grade: DOB: (Last name, First name, special nickname) (2013-2014) A. Contact Information: 1. Please indicate which parent should be contacted first in case of illness or emergency AND which phone number should be used first (cell, home, work). Father (or Guardian) Name: Mother (or Guardian) Name: (Contact 1 st / 2 nd ) (Contact 1 st / 2 nd ) Telephone: Home: ( ) Telephone: Home: ( ) Cell: ( ) Cell: ( ) Work: ( ) Work: ( ) Address: Address: Child lives with: Mother & Father Mother only Father only other (explain) 2. Additional people who are authorized to pick up my child from school if I can t be reached.(valid picture ID will be required.) Name/Relationship Telephone with area code Location/Address (approx. 15 min from ADHUS) a. b. c. B. Permission to Treat or Administer Emergency Medical Care/Authorization to Release Medical Information: 1. I/We, the undersigned Parents/Guardians, in the event of an emergency or injury occurring during school hours, give permission for the evaluation and treatment, in our absence, of the above named student as deemed necessary by a currently licensed health care provider, hospital, emergency medical services or school staff. Every effort will be made to contact the parent/guardian. Care of the injured student will be provided as needed. Care will not be withheld until parent arrives or are notified. I/We understand that the parent/guardian is completely responsible for the financial costs incurred with treatment. 2. I/We, the undersigned, authorize the release of medical information, gathered in the course of a school emergency, to the listed medical care providers and emergency response personnel. I/We authorize the listed medical providers to share any personal health care information that will support the health of the student while in school with the designated Health Care staff. Signature of Parent/ Guardian Date Signature of Parent/Guardian Date 3. Health Care Provider Information: Pediatrician/Primary Health Care Provider: Telephone: Dentist: Telephone: Insurance Coverage: Y / N Company/Carrier Name: C. Medication History: 1. My child will take daily or emergency medication during the school day. Y / N a. Name of drug, dose, frequency, time to be given, date drug therapy started or to be started for each med to be given. 5

2. A current Authorization to Administer Medication in School form is completed by parent and healthcare provider and is filed in the Health Center. Y / N (This form is available in the health center and main office. It must be completed before any medication, including over the counter medications, such as motrin, tylenol, or cough drops may be given by the school nurse during school hours. A handwritten note from a parent is not sufficient to provide medication authorization). 3. Does your child routinely take daily medication at home? Y / N If yes, list name, dose, time given, reason for administration, and any known side effects. D. Medical History: 1. Does your child(ren) have any disease or chronic illness we should know about? Please list below: 2. Does your child currently have Asthma? Y / N If yes, list frequency of asthma attacks, date of last attack and meds taken: 3. Does your child currently have Allergies? Y / N If your child has a strong allergic reaction to any substance, you are encouraged to bring in a completed Authorization to Administer Medication in School for oral Benadryl and/or an injectable Epi -pen, Epi- pen Jr. These will be kept locked in the Health Center. a. Food/Medication Allergies? Y / N Treatment: Reaction/Reaction Time: b. Contact Allergies (bug bites, airborne vapors, dust, pollen, lotions, latex) Y / N Type/Substance: Treatment: Reaction/Reaction Time: c. All students receive milk as part of the school dietary program. If your child may not drink milk, state law requires a note from your child s health care provider. My child may drink milk provided by the school. Y / N 4. Has your child been diagnosed or treated for a vision, speech, or hearing impairment? Does your child wear glasses/contacts or hearing aids? Y / N Please Explain: 5. Has your child been diagnosed or treated for behavioral, developmental or learning disabilities? Y / N Please Explain 6. Does your child require any assistance as defined by the Americans with Disabilities Act? Y / N Please Explain E. Medication Policy: All routine, regularly scheduled or as needed medications and treatments administered in the school setting must be authorized in advance by a licensed health care provider. This includes nebulizer or inhaler treatments for asthma, medications, ointments, or dressing changes to the skin and all over the counter medication (OTC s) such as Tylenol, Motrin, Cough Medicine, and Cough Drops. A note from the parent/guardian does not authorize the school nurse or nurse designee to provide these treatments. Before the nurse can administer any medications or treatments the Authorization to Administer Medication in School form must be completed by the parent/guardian and the student s health care provider. This form must be given to the nurse and filed in the Health Center. The parent/guardian must provide to the Health Center the prescribed medication stored in the original container with an appropriate pharmacy label on each bottle. All labels must include the student s name, dose, route and time of administration of the medication. No student is permitted to carry any medication in his/her pocket or backpack unless special permission is granted. All medication will be kept secure in a locked cabinet in the Health Center and dispensed by the School Nurse or designee. I/We have read and will abide by the ADHUS/FAUHS medication policy. Parent/Guardian Signature Date 6

A.D. HENDERSON UNIVERSITY SCHOOL FAU HIGH SCHOOL Healthcare Provider Authorization for School Administered Medications and Treatments (If applicable) Student Name: DOB: Grade: Last Name, First Name Part I Dear Parent or Healthcare Provider: When considered medically necessary, students may receive medications and treatments, as ordered by a licensed healthcare provider, during the school day. Please complete the following information. Be advised that: Orders are valid for one school year NO MEDICATION or TREATMENT may be given by the school nurse or designee until this form is completed and the medication (properly labeled) is received. THIS INCLUDES OVER THE COUNTER MEDICATIONS SUCH AS TYLENOL, MOTRIN, AND COUGH DROPS. A physician signature and parent signature must be on this form. All medications must be stored in their original containers with an appropriate pharmacy label on each bottle. All labels will include the student s name, dose, frequency, route, time of administration of the medication. Part II Dear Healthcare Provider: The parent initiates this request and has the responsibility for supplying medication and/or treatment supplies. Should the student display any adverse reactions, the parent will be contacted immediately, emergency care will be provided as needed and the medication/treatment discontinued. The parent will be responsible for contacting you for follow-up care as you deem necessary. Please sign below, acknowledging that you understand the procedure for management of side effects to prescribed medications or treatments. Thank you for your assistance. Part III MEDICATION/TREATMENT #1 Name of Drug/Treatment Dosage Route Frequency (include the times of administration and duration) Medication form pill/capsule inhaler ear drops eye drops liquid injectable Known adverse reactions/side effects Prescribed treatment for side effects, if other than as outlined above MEDICATION/TREATMENT #2 Name of Drug/Treatment Dosage Route Frequency (include the times of administration and duration) Medication form pill/capsule inhaler ear drops eye drops liquid injectable Known adverse reactions/side effects Prescribed treatment for side effects, if other than as outlined above / PHYSICIAN NAME (please print) PHYSICIAN SIGNATURE / DATE PHONE # 7

PART IV Parent Permission: I hereby give permission for my child to receive the above medications/treatments during school hours. I understand that medications may be administered by the school registered nurse or designee. This designee may be a non-medical person. If a treatment requires a medical or nursing assessment prior to administration, and a licensed medical person is not available, the medication and/or treatment will not be given. This medication and/or treatment is considered a medical necessity and ordered by a licensed healthcare provider. I hereby release the FAUS District, its agents and employees from any and all liability that may result from my child receiving this medication and/or treatment. / Parent Signature Date Home Phone # Cell # Work # Do Not Write Below This Line School Use Only Comments: Medications/Treatments Received: Date: Amount: Logged in Medication Administration Book: Secured in a Locked Cabinet: Approved By: School Nurse Signature Date: 8

Dear Parents/Guardians, A.D. HENDERSON UNIVERSITY SCHOOL FAU HIGH SCHOOL Keeping you informed, especially in emergency situations, is a top priority at A.D. Henderson University School/FAU High School. As many of you know, the ALERTNOW Notification Service allows us to send telephone and/or e-mail messages to you providing important information about school events or emergencies. We use ALERTNOW to notify you of school delays or cancellations due to inclement weather, as well as remind you about various events, including report card distribution, open house, field trips, and more. In the event of an emergency at school, you can have peace of mind knowing that you will be informed immediately by phone. What you need to know about receiving calls sent through ALERTNOW Caller ID will display the school s main number when a general announcement is delivered. Caller ID will display 411 if the message is a dire emergency. ALERTNOW will leave a message on any answering machine or voicemail. If the ALERTNOW message stops playing, press any key 1-9 and the message will replay from the beginning. The successful delivery of information is dependent upon accurate contact information for each student, so please make certain that we have your most current phone numbers and e-mail addresses. Please fill out your current information below and return to school as soon as possible. All numbers and email addresses listed below will receive standard and emergency messages, and all will be dialed simultaneously. Thank you for your cooperation. If this information changes during the year, please contact Kimberly Oliver at oliverk@fau.edu or 561-297-3077 to let us know immediately. Sincerely, Dr. Tammy Ferguson Principal/Director ALERTNOW INFORMATION FORM Student Name Grade Student Name Grade Student Name Grade Student Name Grade Parent Name Home phone number ( ) Smart Phone? Y or N Text Messages? Y or N Mother s cell phone ( ) Smart Phone? Y or N Text Messages? Y or N Father s cell phone ( ) Smart Phone? Y or N Text Messages? Y or N FAU High Student s cell number ( ) Smart Phone? Y or N Text Messages? Y or N Additional Phone number ( ) Smart Phone? Y or N Text Messages? Y or N FAU High Student s email address E-mail address(es): list as many as you would like to receive messages 9